It is amazing how the brain trust at Tricare can come up with the most ridiculous and unfounded mechanisms with policy changes – especially as it relates for covering ABA for autistic dependents. Let’s make it harder to qualify for coverage, make MORE hoops to jump through in the process AND let’s require measurable results every 180 days from a test not designed to measure the kind of progress they are looking for. Dumber than dumb Tricare! Thanks for the slap in the face to all those military families raising a child with autism!
TRICARE Coverage of ABA – Policy Update July 5, 2013
Summary: Last month, TRICARE revised its policies for coverage of applied behavior analysis (ABA). The changes are significant and represent a drastic shift from how TRICARE covers all other medical care. Autism Speaks is working to develop a response and provide recommendations for policies that reflect good clinical practices and consistently address the medical needs of individuals with autism.
To help families understand these changes, we have drafted the following Frequently Asked Questions page. The information provided is based on the TRICARE Policy Manual changes Chapter
7 Section 3.18 dated June 25, 2013. Families are encouraged to read through the policy changes – we have done our best to summarize the new guidance, but there really is no substitute for going to the original source. We also recommend families contact their TRICARE case manager or their Exceptional Family Member Program to confirm how these changes will affect them.
Frequently Asked Questions:
My son has been prescribed ABA therapy. Will these changes affect our family and when do they become effective?
These changes become effective July 25th, 2013 and will impact all TRICARE beneficiaries needing and currently receiving ABA therapy.
My child is currently receiving services under the ECHO Autism Demonstration, not the TRICARE basic program. Why do these changes affect me?
TRICARE has restructured its ABA authorization and referral process. All referrals and authorizations for ABA must now go through the TRICARE Basic Program. Once authorized, families can receive ABA hours to be covered under the TRICARE Basic Program, the Autism Demonstration (active duty families), and the ABA Pilot (non-active duty family members).
Can you please walk me through the new referral and authorization process?
Referral and authorization of services are required for all ABA care. We have outlined the following steps to help walk you through this complicated process:
1. Parents must get a referral for ABA from their Physician Primary Care Manager (P-PCM) or from a specialized autism provider.
2. The Managed Care Support Contractor (MCSC) will then refer beneficiaries for an “ABA assessment” to be conducted by an ABA provider.
3. The ABA assessment must include psychometric testing using the Autism Diagnostic Observations Scale, second edition (ADOS-2), and the Vineland Behavioral Scale II (VBSII).
4. Based on the results of the ABA assessment, the referring provider must submit a referral to the MCSC for an authorization of ABA. Please note there are significant changes to the minimum information that the referring physician or psychologist must include as part of your referral. All authorizations are good for one year.
What if my ABA provider is not qualified to administer the ADOS-2 or VBS-II?
If the ABA provider conducting the ABA assessment is not qualified to administer the ADOS-2 or the VBS-II tests, your referring provider must provide you with an additional referral to
qualified TRICARE provider that can administer the tests (such as a developmental pediatrician, licensed clinical psychologist, etc.).
What happens if there are wait lists for these providers or I am unable to find a provider in my area to deliver this testing?
The TRICARE policy is silent on this issue. Autism Speaks is aware there is a shortage of specialty care providers in many of our military communities, especially in rural areas. We
are very concerned that the absence of available provides will impede access to care for children.
How often are these psychometric tests required?
The VBS-II must be administered every 180 days and the ADOS-2 is required annually.
Why are all of these testing requirements necessary?
TRICARE is now requiring psychometric testing to verify progress on a beneficiary’s treatment plan. Autism Speaks is very concerned about the new testing requirements and that TRICARE is using the results of the psychometric testing for purposes they were not validated for.
So, my child has to show progress on the psychometric tests to continue ABA services?
Yes. We understand that this represents a significant shift in how TRICARE covers all other medical services and fails to address the challenges and needs individuals with autism often experience.
Are the psychometric tests required by TRICARE sensitive enough to reflect progress made on a child’s ABA treatment plan?
No. It is not standard practice to use the VBS-II or the ADOS-2 to report progress on an ABA treatment plan, and these tests have not been validated for this purpose. Further, results of
standardized tests should never be used to deny a patient care.
How does this affect families with a current authorization for ABA? Will my child need to go through all of these assessments?
The policy is not clear how these new requirements will affect services previously authorized.
I have heard that there are new “discharge criteria” that could terminate ABA coverage for my child. Is this true?
Yes. TRICARE could discharge a beneficiary from ABA treatment if and when any of the following are determined: 1) no measurable progress on psychometric testing has been
made; 2) ABA treatment plan gains are determined not to be generalizable or durable over time and do not transfer to the larger community setting; 3) the patient, family, or caregiver
can no longer participate in ABA; 4) the beneficiary has met all treatment plan goals and no longer requires care; and 5) loss of TRICARE eligibility.
OK, assuming I am able to get through all the hoops to receive ABA, what ABA services are covered?
The MCSC will review the treatment plan, assessment results, and determine “appropriateness of care.” If authorized, beneficiaries can receive up to 20 hours a week of ABA under the TRICARE Basic Program. All ABA services under the TRICARE Basic Program must be delivered by a BCBA or BCBA-D. A beneficiary can also choose to receive services under the Autism Demonstration (for active duty family members) or the ABA Pilot (for non-active duty family members). Both the Autism Demonstration and the ABA Pilot include coverage for services delivered by a BCaBA or an ABA Tutor and are subject to an annual cap of $36,000 per fiscal year.
Can I get direct services by a BCBA under the TRICARE Basic Program and use the Autism Demonstration or ABA Pilot?
Yes. A beneficiary can receive direct services by a BCBA or BCBA-D under the TRICARE Basic Program and receive services from BCaBA or Tutor under the Autism Demonstration or ABA Pilot.
How is non-active duty family member defined? Does this include retirees?
Non-active duty family members include dependents of TRICARE eligible sponsors that are not on active-duty status. This includes retirees.
So, retirees can now get coverage of ABA when delivered by BCaBA’s or Tutors?The ABA Pilot, which is for non-active duty family members, is very similar to the Autism Demonstration and provides coverage of BCaBA’s and Tutors that work under the supervision of a BCBA (subject to same $36,000 maximum).
I’ve heard there are new limitations on treatment duration and age requirements. Is this true?
Yes. Beneficiaries needing treatment beyond 2 years or over the age of 16 must receive a waiver for continued care. Autism Speaks is concerned about the restrictive nature of this ABA policy.
What is my cost share for ABA treatment?
Cost shares will vary based on what program services are delivered. ABA services under the TRICARE Basic Program are considered specialty care. Depending on your TRICARE plan (i.e., TRICARE Prime, TRICARE Standard, etc.), cost shares may apply. Services delivered under the Autism Demonstration remain the same and continue to be based on rank and are assessed monthly. Cost shares under the ABA Pilot equal 10% of the total charge. It is important to note that cost shares under the Autism Demonstration and the ABA Pilot do not accrue to the beneficiary’s deductible or out-of-pocket maximum.
Please keep us informed about your experiences with new ABA policy. You can email us at